Does medical diplomacy work? One can argue medical diplomacy improves strategic relations with foreign countries by providing free medical care “to win hearts and minds.” The most visible medical diplomacy is using hospital ships such as the USNS MERCY and the USNS COMFORT. In response to the 2004 Tsunami, USNS MERCY deployed and provided medical care to tsunami victims inIndonesia and other affected areas. A more recent example is the USNS COMFORT deploying toHaiti to help earthquake victims.

In “Let’s have a Fleet of 15 Hospital Ships” LT Jim Dolbow argues the U.S. enjoyed a huge favorable swing in public opinion after MERCY’s 2005 humanitarian mission. According to Terror Free Tomorrow following MERCY’s visit, a remarkable 85 percent of Indonesians and 95 percent of the people of Bangladesh were favorable to MERCY’s mission. Because of such positive response, the United States conducts biannual deployments with its hospital ships for theatre security cooperation missions. Hospital ships support a larger maritime strategy by enabling the Navy’s expanded core competency of “humanitarian assistance and disaster response.”

On the other hand, in “The Decline of America’s Reputation: Why?” it states following the 2004 tsunami, ratings only increased from 15 to 38 percent. There was not a similar rise in Pakistan after U.S. earthquake relief in 2005. This is quite a contrast compared to the Terror Free Tomorrow poll. In 2007, the Pew Research Center wrote “the impact of this humanitarian assistance should not be overstated – most of the same misgivings aboutAmerica seen throughout the Muslim world can be found inIndonesia andPakistan, and solid majorities in both countries continue to have a negative impression of the U.S.”

What are some costs of hospital ship medical care? In “Advancing Humanitarian Aid: Infusing the era of hope with a dash of accountability”, Professor Leslie F. Roberts argues much of the aid has little influence. Roberts notes “between 21 January and 11 March, the [COMFORT] with its 10 surgical theatres served 871 patients. Data presented by a senior USAID official suggested, excluding medical personnel costs, this highly visible relief effort cost >US$30,000 per patient. While this may be typical of the costs for similar surgeries in Western Europe or North America, it is orders of magnitude over expected surgical costs in humanitarian settings, or hospitals in Port-au-Prince.” Per the Daily Caller, “The Navy spent 2 million gallons of fuel treating fewer than 1,000 people – if it’s using marine fuel which is roughly $4 a gallon, that’s $8 million in fuel. That’s roughly $9,184 per patient, just to keep fuel in the tanks.” This seems like a lot of money to spend when theUnited States citizens have difficulty paying their own medical bills.

What if the United States Government got rid of hospital ships? If there were no hospital ships, other countries would not expect theU.S. to deploy one to give out free medical care. Warships can conduct humanitarian assistance and disaster relief. Amphibious ships such as the USS BOXER and aircraft carriers such as the USS NIMITZ have robust medical facilities and have superior boat and helicopter transport. Money saved by getting rid of hospital ships can be diverted to improving medical facilities on regular warships already forward deployed around the globe.

Do hospital ships provide benefits that a warship cannot? When the tsunami hit Indonesia in 2004, it took approximately a month for MERCY to arrive in Indonesia. The arrival was too late to treat initial wounds. U.S. Navy ships such as the Abraham Lincoln were already on station within days. In “Developing Soft Power Using Afloat Medical Capability”, CDR Salamander pointed out, “a study conducted by Center for Naval Analyses on host nation impact based on the recent T-AH and LHA/LHD 21 humanitarian assistance deployments reveals that ‘it does not matter whether it was a hospital ship or an amphibious ship as both ships functioned equally well in terms of positive impact to the host nations.’ . . . Speed of response is the most critical element of a successful humanitarian assistance and disaster relief operation. The ability to move people, equipment, and supplies throughout the operational area determines whether the operation is a success. Both hospital ship and amphibious ship are the right platforms for humanitarian missions, with the latter having an advantage on disaster response due to speed and global forward presence.”

No matter the results of this decision, the Navy will continue its expanded core competency to provide humanitarian assistance and disaster relief close to our shores and abroad.

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About LCDR Michael Pugh

Lieutenant Commander Michael Pugh is a Surface Warfare Officer currently attending Command General Staf fCollege at Fort Leavenworth, Kansas. He served on USS GEORGE PHILIP (FFG 12), USS NIMITZ (CVN 68), USNS MERCY (T-AH 19), USNS COMFORT (T-AH 20), USS THACH (FFG 12), and USS BOXER (LHD 4). The views expressed in this article are the authors’ alone and do not represent the official position of the Department of the Navy, the Department of Defense or the U.S. Government.

I’ve often considered that some kind of specialized LHA type “humanitarian/emergency/relief” vessel either pure USN or USN/Coast Guard could replace the two WW2 era hospital ships. One based on each coast would be able to respond to natural disasters (imagine Katrina or the perennial hurricane disasters of the Caribbean being responded to from such a Norfolk based ship, etc.)

I’d think ideally such a vessel would be nuclear powered (although politically I know that’d be a problem) so that it could have plenty of surplus power for running operations ashore…and perhaps also capable of getting itself into and out of tricky littoral waters with ease, maybe even to the point of operating similar to the old LST so it could stand up anywhere without port/dock facilities.

http://CGBlog.org Chuck Hill

Suspect it would be more effective to have hospital modules that could be mounted on ships already near the area. Might be a good use for LCS. Several could concentrate in one area or disperse as required.

B.Smitty

Rather than large, specialized, low-density hospital ships, we would be better served by more numerous, forward-based, general purpose utility vessels that can be configured with containerized hospital modules.

Michael

Might be handy to consider ways to reduce the cost of the ships themselves. Buying old cruise liners, for example, gives plenty of room for operating rooms, rehab centers and beds in hulls that were designed for efficiency (they were built by businesses) and operation in poorly equipped areas (How many tropical paradises are equipped with first-rate port facilities?).

I’ve also seen a blog post by a guy who suggests building lots of smaller ships on hulls that can handle littoral and some riverine environments.

Byron

The driving principle will be…money. Fuel. Manpower. Maintenance.

Allen

Yes Hospital ships may have their uses, but they may be an expensive boondoggle. The big drawback with hospital ships is they take much too long to get to a natural disaster devastated area. Yes they can treat a lot of people once they are there, BUT experience has told us that many countries/peoples do not take advantage of those capabilities especially if they arrive late. I think a better solution might be something like a modern fast mobile hospital like the Korean war MASH units. Maybe something that could be folded up and transported to an area like Hati in big C-5A transports. Modules that expand into operating theaters with folding walls, patient recovery and wards that yes may even be tent type with semi rigid floors and walls. Spray the tent tops with rigid foam insulation, and replace the tent material each time after the unit is used. The modules would have to be sized such that they could be lifted by Helo to shift them from a nearby serviceable airport that can take a C-5A to any navy ship with a large enough landing pad where the modules could be set up and still support Helo ops for medivac. Ships would provide power, waste disposal, food in galleys, and berthing for some assigned personnel. That would include carriers as well as anphib ships. Personnel would be transported by commercial or military transport. Smaller units for smaller emergencies that were self sustaining including electrical power and food prep or waste disposal could be transported by C-17 and be set up near or on the airports or transported into urban areas as necessary. For stand alone units, the personnel would have to include security personnel and techs for infrastructure support.

Collapsed modules ready for flight cargo transport could be prepositioned on east and west coast on Guam or Diego Garcia, maybe Italy at large air force bases or even on bases in other countries. Perishable drugs and food stores modules would be assembled here in US for transport to meet with newly set up hospital modules and with the personnel. Arrival and set up time could be as little as 1 or two days depending on how long it takes our cargo planes to meet with the waiting modules, flight time across the globe and in theater airport capability. Fly to another nearby country, refuel and await final destination determination or arrival of our nearby ships for setup. Hospital ships might still be maintained for bigger emergencies with much longer delay times. Paying for warehouse storage should be much cheaper than paying for operational ships and crews.

A small permanently assigned maintenance team could be flown from one stored module location to another to open the modules and repair/replace outdated components and do upgrades every 6 months or so. Empty drug and food modules would be positioned at large hospitals to be filled in hours with specified items, the modules sized to fit in commercial passenger or cargo planes to be flown to meet with hospital modules at the destinations. Multiple modules from different sources would ensure adequate supplies.

William Horn

Another proposed cutback in the Navy to be expected. Why are we maintaining a Navy for the purpose of humanitarian operations? That is a different basis than having capabilities primarily to support large-scale combat operations in an expeditionary mode in distant areas which can be utilized for humanitarian operations on a not-to-interfere basis. The military medical system is being so centralized and civilianized that these ships, no doubt, are inconvenient, and it can be argued that we need all our medical personnel in hospitals for treatment of wounded, active duty personnel, and their dependents. Can’t see where these ships deny medical personnel from crewing deployed ships, as hospital ships are largely crewed by augmentees from naval hospitals.

Our military has been operating for some ten years deployed in low intensity land wars and a permissive environment. Should we be involved in a larger conflict with a significant state military force, our deployed forces could well be faced with urgent needs for medical care to support forces operating in a mobile mode away from fixed bases. This is a capability that the Navy must maintain against uncertainty and the imperative to conduct full intensity conflict in the national defense.

v/r,

Bill Horn

Byron

Mr. Horn, what are you willing to give up to maintain the hospital ships? The budget is finite, warships are going away, the Navy is shrinking…what can you do without?

leesea

BSmitty has the answer right. Having more large T-AH19 size ships is NOT an improvement, having more handy-sized ships with multiple capabilities is.

Perhaps the author should have mentioned the hospital ship designs used by OTHER navies?

If the author is suggesting that warships with smaller medical spaces can supplant the integral Medical Treatment Facility on a T-AH is absolutely wrong. The manning and capabilities far exceed any warship.

What needs to be asked is does the USN NEED to build these kind of soft power functions into a warship? Or more precisely should HA/DR be performed by warships? Those ships only bring the first responders and connectors, and then LEAVE the scene before the crisis is corrected.

leesea

BTW the concept I suggested previously was to preposition sealift ships in foreign ports in an reduced status crewed by merchant mariners. The medical items and relief materials could be stored in a warehouse alongside. When a HA/DR mission was called for, the crews could loard the ship while military teams could fly to that port and board.

That way ships loadout would be tailored to crisis and they could stay on-station longer.

leesea

I do believe that port entry is an issue. Look at how the USN ships were denied entry by Myanmar? I know from experience that entry of sealift ships and naval auxiliarires into to foreign waters is easier than for a warship.

Afterall what country would like a Marine assualt ship lingering in its territorial waters? Even if those Marines are the first responders and the big helos & boats they use are needed, I suspect that some countries are happy to see them leave.

leesea

Chuck the JHSV is built to hold a medical facility in containers, but that capability is very limited. Might do for some small HA mission but not a major DR one.

Mike Spence

Huh? All this talk about relevance based solely on humanitarian assistance? What about war-fighting? I thought the hospital ships were in reserve for a major conflict and would be brought to higher readiness status in-line with other Reserve units. This discussion entirely misses that point. The periodic humanitarian deployments were meant to exercise the platforms and their facilities with a by-product of generating good will. If we’ve determined that they have little use in major conflict, then let’s get rid of them.

leesea

Spence, Wrong T-AHs deploy ANNUALLY to on Partnership missions and have been used for crisis responses frequently. The missions that hospital ships go on are FAR more than shakedown crusises. The author’s first section tried to tie humanitarian assistance to medical diplomacy be simply looking at ONE metric, and failed to make the point IMHO

Scott

I’d rather have more big deck amphibs that can flex from CVL (like for ODYSSEY DAWN)to HA/DR (forget which ship did this a few years ago as a regular deployment) as necessary. Combine that with an in-theater JHSV (LCS?) medical module and you’d have a pretty robust capability – but only if enough ships were available. Not sure of the exact budget math, but I’d be willing to trade a CVN for two big deck amphibs plus a dozen or so JHSV’s. This trade is not just for HA/DR missions, but across the spectrum of warfare areas.

Julie Feinsilver, Ph.D.

Gentlemen: returning to the initial post, medical diplomacy works best when it is quick, relevant, and cost-effective. From what I have read, hospital ships are just too expensive, probably even for a major conflict as suggested by Mike Spence. The point is to get the mobile medical units into wherever quickly and use them on terra firma. In times of shrinking budgets, but also a focus on improving relations with other countries through various forms of public diplomacy exercising our soft power, Allen’s suggestions make sense to this non-Naval expert.
BTW it is good to see this discussion!

LCDR Michael Pugh

All, I really appreciate the great comments!

@Dave Watkins – Regarding the LHA/LHD capabilities, you are correct, the warfighting Navy has a lot of medical capabilities. “Paint it White” by M. Ittleschmerz proposes a solution using existing ships. Is this what you are thinking about?http://blog.usni.org/2011/03/17/paint-it-white/

As for the nuclear power route, I do not think the hospital ship meets the cost benefit for such an upgrade (yet). When responding to a humanitarian crisis, a nuclear protest could be an extra unnecessary political burden when dealing with a crisis or humanitarian assistance.

@Chuck Hill – LCS is supposed to allow a modularized configuration based on a mission set. That could be a future capability that the Navy can develop.

@B.Smitty – The containerized solution might work on the larger ships but the numerous forward deployed ships such as FFGs, DDGs, and CGs are not designed to hold containers. It could come at a cost of another capability: say if the Navy filled the helo hangar or flight deck with containerized medical capability but that would lose their helo capability. Larger ships could forgo some capability or throughput such has hold less marine equipment, or less aircraft with the medical equipment loaded in its place. In the uncertain world, it would be a decision with risk. It would also increase costs such as expiring unused medical supplies, medical staff, and maintenance of the equipment would impose logistical issues. It would also be a best guess of an uncertain event that we have the right supplies and equipment on the ship. But, I do agree it could be a solution if the United States believes the benefits outweigh the costs.

@Michael – Old cruise liners could be a solution, but it would still incur a substantial cost to outfit, maintain, fuel, and staff.

@Allen – great idea to containerize the medical equipment into smaller packages but here are some difficulties to consider. After a large tsunami or earthquake, the airfields could be damaged preventing the medical containers to be put in the right place at the right time. Large aircraft with heavy loads need long landing fields and many of the places that were visited by the hospital ship do not have large airports near them that could land large aircraft. Ships can carry a LOT more equipment than aircraft. Around 400x more equipment can be moved by ship than one large aircraft. I do not think parachuting expensive medical equipment into a disaster area would be wise, the population could be hostile, and could easily overwhelm a smaller organization. Hospital ships do bring a whole package, security, a safe place to work, modern equipment all set up ready to go, and the appropriate processes for a modern working hospital.

LCDR Michael Pugh

@Bill Horn – Military service members still receive the medical care that they are entitled to. If a medical facility cannot provide the doctor (because he deployed on a hospital ship), he would see another doctor with the same capability.
As for maintaining the capability, I argue a carrier strike group or amphibious ready group have robust medical capabilities and designed to handle a number of casualties. In the last large scale conventional war in Iraq, the hospital ship was under utilized. Most patients were medically treated by land forces then med-evac’d to Germany, bypassing the hospital ship. One could argue the United States was lucky and it was good to have the excess hospital capability just in case.

@Byron – I agree completely and that is the question I am asking people to think about with the article.

I did not include other hospital ships because I did not initially think it impacted the Navy’s cost decision…that is unless the United States needs to compete with China in hospital ships and medical diplomacy. That topic is probably beyond the scope of my original article.

With respect to the capabilities of a warship and a hospital ship, you are correct. But does the cost outweigh the benefits? I do argue that there is already significant capability with amphibs and carrier strike groups. Does the U.S. need the extra capacity and throughput in this uncertain world? Is the cost justified?

For your question/comment: “What needs to be asked is does the USN NEED to build these kind of soft power functions into a warship? Or more precisely should HA/DR be performed by warships? Those ships only bring the first responders and connectors, and then LEAVE the scene before the crisis is corrected.”
One of the expanded core competencies for the U.S. Navy is humanitarian assistance. So the Navy has to plan and enable accomplishing that core competency. The question would be with the finite budget, what should we prioritize? I argue yes – the Navy needs to prioritize and budget for humanitarian assistance and disaster relief. The best way to do that is with the first responders.

For the configuration of hospital ships, the hospital ships have a reduced operating status with a minimal crew that maintains the equipment and the leadership to active the ship when required. It takes about 5 days for the hospital ship to activate and sail away to a mission. It was done in less days for the Haiti mission. This includes a load out of supplies, food, and required personnel. Additional medical personnel can picked on the way to the mission. (i.e. a MERCY picks up medical personnel in Hawaii or Guam on its way to Indonesia)

Regarding your comment: “Afterall what country would like a Marine assault ship lingering in its territorial waters? Even if those Marines are the first responders and the big helos & boats they use are needed, I suspect that some countries are happy to see them leave.” I want to point out one of usni.org’s bloggers CDR Salamander pointed out and mentioned in the article above: In “Developing Soft Power Using Afloat Medical Capability”, CDR Salamander pointed out, “a study conducted by Center for Naval Analyses on host nation impact based on the recent T-AH and LHA/LHD 21 humanitarian assistance deployments reveals that ‘it does not matter whether it was a hospital ship or an amphibious ship as both ships functioned ***equally*** well in terms of positive impact to the host nations.’

LCDR Michael Pugh

@Mike Spence: Great comment. May I ask, what is the guarantee/probability that the U.S. will not enter a major conflict in the near future? And, if the U.S. enters a major conflict, do the existing capabilities meet those requirements?

@leesea: What other key metrics do you propose to look at? Cooperation with other countries, cooperation with NGOs, training (exercise platforms and facilities). What metric does the hospital ship do that the warship cannot? Warships go out on the partnership missions and complete the same metrics. It is back to performing “equally” which I mentioned above. It is my opinion that the hospital ship does look better in a photograph. Which metric is that, and does that metric REALLY matter? (if you have a ref that compares it with a warship, I would love to see it because I could not find it.

LCDR Michael Pugh

@Scott – CVNs are still in high demand and can perform functions that a big deck amphib cannot (and vice versa).

@Julie – I know NGOs have done their missions much cheaper since they are usually utilizing ground facilities, donated supplies, and donated skilled manpower (volunteer doctors). Plus they could use local skilled labor at local prices (vice U.S. doctors).